While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?
Monitor I&O
Check blood pressure
Assess pain level
Measure oxygen saturation
The Correct Answer is B
A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
Correct Answer is A
Explanation
A) Pancrelipase is an enzyme replacement therapy used to aid in the digestion of fats, proteins, and carbohydrates, and its use may lead to steatorrhea (fatty stools) as a common side effect.
B) Pancrelipase is typically administered with meals or snacks to aid in digestion; there is no need to administer it prior to antacids.
C) Pancrelipase is taken with meals or snacks to assist in digestion, so this statement is incorrect.
D) There is no need to rinse the mouth after taking pancrelipase; it is a medication designed for oral ingestion.
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